Utilization Review & Benefits Verification Specialist

Program: Adolescent Residential Treatment – Mental Health
Department: Clinical Operations / Revenue Cycle
 

Position Summary

The Utilization Review & Benefits Verification Specialist supports the Adolescent Residential Treatment Program by managing insurance benefits verification, initial and continued stay authorizations, and payer communications to ensure services are medically necessary, authorized, and reimbursable. This role works closely with admissions, clinical staff, case management, and billing to maintain coverage continuity and reduce denials.

This position is hands-on and cross-functional, requiring strong attention to detail, comfort with clinical documentation, and the ability to manage multiple payer timelines within an EHR system.

Essential Duties & Responsibilities

1) Benefits Verification & Intake Support

• Perform      insurance benefits verification for adolescent residential mental      health services prior to admission, including: 
  • Eligibility and effective dates
  • Mental health benefits
  • Deductibles, copays, coinsurance, and out-of-pocket maximums
  • Authorization and notification requirements
• Clearly communicate benefit details and financial responsibility to admissions and leadership.
• Document all benefit verification details accurately in the EHR and/or tracking tools.

2) Authorizations & Concurrent Utilization Review

• Obtain and manage initial authorizations for adolescent residential admissions.
• Coordinate and submit continued stay (concurrent) reviews to ensure uninterrupted coverage.
• Track authorized days, next review dates, and payer deadlines using the EHR system.
• Notify internal teams of authorization decisions, changes, or risks in a timely manner.

3) Medical Necessity Documentation (Adolescent Mental Health Focus)

• Review clinical documentation to ensure it supports residential level of care for adolescents, including: 
  • Presenting symptoms and DSM-5 diagnoses
  • Safety concerns (e.g., suicidal ideation, self-harm, aggression, elopement risk)
  • Functional impairment at home, school, or community
  • Family dynamics and supervision limitations
  • Failed or insufficient response to lower levels of care
  • Treatment engagement, progress, and ongoing clinical needs
• Collaborate with therapists, nursing, psychiatry, and case management to obtain complete and consistent documentation.

4) Payer Communication & Clinical Review Summaries

• Prepare clear, concise clinical summaries for payer reviews that demonstrate medical necessity for continued residential treatment.
• Submit reviews through payer portals, phone, fax, or secure email.
• Coordinate peer-to-peer reviews with the Clinical Director, psychiatrist, or licensed provider when required.
• Maintain professional and timely communication with insurance representatives.

5) Denials Prevention & Appeals Support

• Identify potential denial risks.
• Assist with appeals by gathering records, drafting timelines, and supporting clinical appeal narratives.
• Track denials and payer feedback to identify trends and recommend improvements.

6) Discharge Planning & Step-Down Coordination

• Work with case management to ensure discharge plans align with payer      expectations and clinical readiness.
• Document discharge barriers and aftercare planning to support continued stay when      clinically indicated.

7) Compliance, Quality & Small-Team Support

• Maintain HIPAA compliance and follow internal documentation standards.
• Ensure UR and benefits verification activities are accurately recorded in the EHR.
• Participate in audits, chart reviews, and process improvement initiatives.
• Assist with related operational tasks as needed in a small-team setting.

Qualifications

Required

• 1–3 years of experience in utilization review, benefits verification, prior authorizations, or behavioral health revenue cycle.
• Experience working with adolescent mental health services strongly preferred.
• Strong organizational skills and ability to manage multiple deadlines.
• Excellent written and verbal communication skills.
• Proficiency with EHR systems, payer portals, and Microsoft Office (Outlook, Excel, Teams).

Preferred Qualifications

• Residential mental health experience with adolescents.
• Appeals and peer-to-peer coordination experience.
• UR or case management certification (e.g., CPUR), if applicable.

Core Competencies

• Detail-oriented and deadline-driven
• Strong clinical documentation literacy
• Professional payer communication skills
• Collaborative and supportive of clinical teams
• Ability to work independently in a fast-paced, small-company environment